General Permits (5435)

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Applicant Name
Address
City
CERTIFICATION OF EXEMPTIONS®�
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coast I sources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0 3.
Phone Number
Project Location (County, State Road, Water Body, etc.)
State
.. I ..
Type and Dimensions of Project % ` f-
The proposed project to be located and constructed as described
above is hereby certified as exempt from the CAMA permit re-
quirement pursuant to 15 NCAC 7K .0203. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
zip 2 t,:' r_ y .,
This certification of exemption from requiring a CAMA permit is
valid for 90 days from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
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Any person who proceeds with a development without the con-
sent of a CAMA official under the mistaken assumption that the
development is exempted, will be in violation of the CAMA if there
is a subsequent determination that a permit was required for the
development.
The applicant certifies by signing this exemption that (1) the ap-
plicant has read and will abide by the conditions of this exemp-
tion, and (2) a written statement has been obtained from adjacent
landowners certifying that they have no objections to the
proposed work.
Applicant's,signature -- _
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSIBOATLIFT/BOATHOUSE)
7a(-7a49
I hereby certify that I own property adjacent to ll e 's
(Name of Property Owner)
property located at I cj Lc J; i e r NV-4 Qd.
(Lot, Block, Road, etc.)
on klawPorf k;f-P-v" , in Car tre t— , N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that
location, and, I have no objections to his proposal. I understand that a pier/mooring
pilings/boatlift/boathouse must be set back a minimum distance of fifteen feet (15') from my area
of riparian access unless waived by me.
I do not wish to waive the setback requirement.
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
Signature
Print or Type Nam
Telephone Number
Date: (o - b

ADJACENT RIPARIAN PROPERTY OWNER STATEXIENT
(FOR A PIERIMOORING PILINGS/BOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to LU , ` , (I �� �f �� 's
r (Name of Property O er)
property located at 9 n, v e r A PC) .
(Lot, Block, Road, etc.)
on �'aupuf-� 0,;y e� , in CQ,,-fie i -� 1 , N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that
location, and, I have no objections to his proposal. I understand that a pier/mooring
pilings/boatlift/boathouse must be set back a minimum distance of fifteen feet (15') from my area
of riparian access unless waived by me.
I do not wish to waive the setback requirement.
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
Sig ature )
Print or Type Name
Telephone Number
Date: fy �d ' 4 U